Tips for Treating Xerostomia

The dental management of patients experiencing xerostomia begins with thorough patient education and the identification and treatment of the underlying cause.^1,2 Treatment includes local and systemic stimulation of salivary glands, palliative treatment for symptomatic relief, and the prevention and treatment of oral complications.^2,3

REDUCE THE CARIES RISK

Patients with xerostomia may stop chewing and reactively modify their diet to a liquid or semiliquid diet rich in fermentable carbohydrates in order to compensate for oral dryness. Decreased mastication exacerbates the condition because periodontal mechanoreceptors and mechanical stimulation of the oral mucosa and tongue are required stimuli for salivation.^1,4 Consequently, patients should be provided nutritional counseling to minimize any negative effects from reactionary diet alterations.¹

Mastication stimulants increase salivation, therefore, the use of sugar-free gums, hard candies, and mints are highly recommended for the relief of symptoms in patients with residual salivary capacity.³ Studies show that daily gum chewing increases parotid gland function and salivary pH.^5,6 The use of gums sweetened with sugar alcohols, such as xylitol and sorbitol, can prevent caries development.⁷

The consumption of citrus drinks and candies is discouraged because they accelerate the development of caries.¹ Although citric acid is capable of stimulating salivation, its use should be discouraged because it causes mucosal irritation and presents the added risk of tooth demineralization.³

LIFESTYLE CHANGES

Patients with xerostomia can make lifestyle changes to control and prevent dental caries that include adhering to a rigorous oral hygiene regimen and noncariogenic diet (low sugar/ fermentable carbohydrate diet).² The need for meticulous plaque control via diligent oral hygiene is necessary for patients with xerostomia. Brushing twice a day with a soft-bristled toothbrush and the use of a lowabrasive, highly-fluorinated toothpaste is recommended, accompanied by a sodium fluoride mouthrinse.^8,9 Because of low salivary flow rates during sleep, the need for good oral hygiene is required before going to bed as well as after breakfast.⁴ The recommended fluoride-delivery system should depend on the clinical need and compliance of the patient.¹

Two common sources of fluoride in dentifrice include sodium fluoride and monofluorophosphate. The fluoride from sodium fluoride is readily available to the oral cavity following its use, however, the fluoride from monofluorophosphate must undergo a hydrolysis step to be released. This may explain the greater anticariogenic effect with the use of the sodium fluoride delivery system.¹⁰ The application vehicles available for sodium fluoride and monofluorophosphate include gels, rinses, lozenges, and chewable tablets.¹¹

Sodium lauryl sulfate (SLS) is a foaming agent commonly found in toothpaste and mouthrinses. SLS has a high protein affinity and is a strong denaturing agent. As such, the use of dental products containing SLS is strongly discouraged for patients with xerostomia.¹² Toothpaste formulated for children does not usually contain SLS and should be considered for xerostomic patients. In patients with a high caries rate, a prescription fluoride dentifrice or gel may provide greater benefit.^13,14 Suitable topical fluoride gels should be applied in custom- fitted trays and have neutral pH and a fluoride concentration of 0.4% to 1.25% fluoride ion.³ For high-risk patients, like those receiving daily radiation therapy, the use of a highpotency fluoride and chlorhexidine is effective.¹⁵

Patients should be advised against the use of caffeine and alcohol-containing products, including alcohol-based mouthrinses, to avoid oral dehydration.^3,16 Patients should be advised to sleep on their side to reduce mouth breathing and its associated drying effect, in addition to using a bedside cool air humidifier. The humidifier should be started 1 hour before bedtime and left running throughout the night to reduce oral dryness discomfort.¹ Patients should be urged strongly against the use of tobacco.³

Xerostomia patients should be advised to schedule frequent recalls for early diagnosis of oral sequelae.¹ Patients are urged to perform their own daily oral self-examinations in order to detect oral ulcers and to communicate unusual findings.³ The placement of sealants and the application of topical fluorides should be considered. The use of topical fluoride may be beneficial to patients with a high coronal and/or root caries rate. This strategy will help in the prevention of caries and may reverse any extant decalcification.² Fluoride varnishes are advised to prolong the exposure to fluoride, an approach that may be beneficial to prevent xerostomia-associated caries.²

PHARMACOTHERAPEUTICS

Medications are available to stimulate salivation. Pharmacological agents have a lasting effect throughout the day.³ The cholinergic drugs (medications that provide similar effects as the parasympathetic nervous system) pilocarpine and cevimeline are approved for xerostomia patients.^17-19 Pilocarpine is also effective in patients who have undergone radiation therapy or bone marrow transplantation.^20,21 Pilocarpine stimulates muscarinic receptors, leading to the secretion of water and electrolytes if the patient has a sufficient amount of functional salivary gland tissue.¹ Initial doses of pilocarpine should be administered 30 minutes before meals, in 5 mg tablets, three to four times a day, with a usual dose range of three to six tablets per day, not to exceed two tablets per dose.^1,3 To minimize side effects and prolong the drug’s action, slow-release preparations of pilocarpine have been developed. New modes of delivery are also being researched including loading nanoparticles with pilocarpine.²²

Cevimeline is another cholinergic agonist used to induce salivary function. Recommended dosage for cevimeline is 30 mg three times a day. It is capable of inducing salivation with minimal adverse cardiac and pulmonary effects because cevimeline has a high affinity for the M3 muscarinic receptor subtypes found on salivary and sweat glands.³ However, cevimeline use is contraindicated in asthma patients or those who have narrow- angle glaucoma.

Bethanechol is another cholinergic drug that increases salivary flow and is capable of increasing salivation in radiation-induced xerostomia patients. Recommended dosage is 25 mg three times a day.³ 

Sweating is the most common side effect of cholinergic agents. The central nervous system is also affected leading to increased heart rate and blood pressure, as well as dizziness, chills, and headaches. Pulmonary and cardiovascular effects are also noted and tend to limit the use of these cholinergic medications in certain patient populations.¹

Anethole trithione is specifically used to treat Sjögren’s syndrome-associated xerostomia. As compared to the other salivary enhancing drugs mentioned, anethole trithione increases the number of receptor sites on the salivary acinar cells. A study showed that patients with Sjögren’s syndrome experienced relief from xerostomia when anethole trithione was administered in 25 mg doses three times a day.²³ Synergistic effects on salivation were observed when a combination of pilocarpine and anethole trithione was administered.²⁴

ALTERNATIVE TREATMENTS

Alternative medical therapies are used by some patients to manage symptoms of xerostomia. Acupuncture may increase parasympathetic activity, causing a release in neuropeptide, stimulating salivary flow and secretions.^31,32 The daily ingestion of 2,000 units of gamma-linoleic acid (found in evening primrose oil) for at least 6 weeks may increase parotid and submandibular salivary flow, but the mechanism of action is not well understood.³³

The use of low doses of human interferon- alpha in lozenges increases salivation in Sjögren’s syndrome patients.^25,26 One study demonstrated that increased salivation and relief of xerostomic and xeropthalmic symptoms were possible in patients with primary Sjögren’s syndrome when administered 150 IU of interferonalpha three times a day.²⁶

When a patient’s complaint of xerostomia is a side effect of a medication, an alternate medication that does not employ the same mode of action may be prescribed. The dental professional should consult the patient’s physician and pharmacist if an elimination or change of medication is being considered.¹ Alternatively, to increase salivary flow, the dosage regimen can be adjusted.²⁷ Patients are urged to coordinate the timing of the dose of necessary medications with meal times to allow sufficient salivary flow during the eating process, counteracting the drying effect of these medications.¹ Because salivary flow is lowest during sleep, patients should avoid taking medications before bedtime.²⁸

Patients with xerostomia should also increase their fluid intake.¹ Patients should be encouraged to place ice chips in their mouth and sip water throughout the day to provide moisture and possibly provide relief to dry mouth symptoms.^2,3 Sipping water during meals may not only aid in swallowing but also facilitate taste perception.³ Although water may clean and hydrate the oral tissues and possibly alleviate symptoms, it is not a substitute for saliva.² Water lacks the buffering capacity, lubricating mucins, and protective proteins of true saliva and is a poor mucosal wetting agent.¹ Whole or 2% milk is a better option due to its moisturizing properties that can aid in swallowing.¹ Swabbing olive oil across the oral mucosa to act as a lubricant may be helpful.²⁹ Use of glycerin swabs is contraindicated due to their drying effect on the oral mucosa.

SALIVA SUBSTITUTES

Over-the-counter saliva substitutes specifically formulated for patients with xerostomia are  available as solutions, sprays, chewing gum, dentrifices, and gels.² These saliva substitutes may also promote salivation.³⁰ For patients with extremely low salivary flow rates, the use of saliva substitutes based on polyacrylic acid and xanthan gum are recommended.³ Formulations contain salts; thickening agents to increase viscosity (carboxymethyl, hydroxymetholcellulose, or animal mucins); parabens (inhibits bacterial growth); and sugar-free flavoring agents (xylitol or sorbitol).¹ Salivary substitutes tend to be shortacting, providing relief for a limited period.² They are most effective when applied before sleeping or speaking. Constant reapplication and cost are two other problems associated with the use of salivary substitutes. Saliva substitutes do play a role in the relief of symptoms associated with xerostomia, especially in those patients with no residual salivary gland function.

Partially or fully edentulous patients with decreased salivary flow are susceptible to pain from denture irritation, mucosal ulcerations, and fungal infections as well as a loss of retention.^1,27,34 Patients should be educated about the importance of a well-fitted prosthesis and discouraged from wearing their denture(s) at night when there is a decrease in salivation.¹ Dentures should be to be soaked overnight in water, and routine brushing and the use of denture cleansers is integral to their effective wear.^1,3 Patients should consider spraying their oral mucosa and the tissue surface of their prostheses with salivary substitutes throughout the day. The development of candidiasis secondary to xerostomia can be treated with pharmacologic rinses, creams, lozenges, and systemic agents.¹ The action of topical mouthrinses and ointments occurs on contact and patients should avoid eating or drinking for 30 minutes to 1 hour following application to prolong medication contact time.¹ Nystatin is a commonly prescribed mouthrinse that contains more than 50% sucrose and may increase the risk of caries.¹ Antifungal agents in lozenge form may not be well-accepted by xerostomia patients due to associated mucosal trauma.¹ Systemic antifungal agents, such as ketoconazole and fluconazole, may interact with other medications.¹ If a patient with dentures develops candidiasis, the dentures may be cleaned overnight with a 0.2% chlorhexidine solution or twice a day with a 1% chlorhexidine gel.³

CONCLUSION

Xerostomia is a prevalent, under-recognized, underdiagnosed, and undertreated condition that may significantly impact quality of life for older adults, patients undergoing radiation and/or chemotherapy, and patients on polypharmacy. As the median age of the world’s population increases, health professionals must be able to assess salivary adequacy and consider therapeutic interventions, including prescription drugs, when indicated. The use of fluoride and calcium phosphate products may be recommended whenever xerostomia occurs to reduce the risk of root and coronal caries that often occurs as sequelae to xerostomia.

REFERENCES

1. Diaz-Arnold AM, Marek CA. The impact of saliva on patient care: a literature review. J Prosthet Dent. 2002;88:337-343.
2. Guggenheimer J, Moore PA. Xerostomia: etiology, recognition and Treatment. J Am Dent Assoc. 2003;134:61-69.
3. Gupta A, Epstein JB, Sroussi H. Hyposalivation in elderly patients. J Can Dent Assoc. 2006; 72:841-846.
4. Humphrey SP, Wialliamson RT. A review of saliva: normal composition, flow and function. J Prosthet Dent. 2001;85:162-169.
5. Polland KE, Higgins F, Orchardson R. Salivary flow rate and pH during prolonged gum chewing in humans. J Oral Rehabil. 2003; 30:861-865.
6. Ly KA, Milgrom P, Rothen M. The potential of dental-protective chewing gum in oral health interventions. J Am Dent Assoc. 2008;139:553- 563.
7. Burt BA. The use of sorbitol- and xylitolsweetened chewing gum in caries control. J Am Dent Assoc. 2006;137:190-196.
8. Wu AJ. Optimizing dry mouth treatment for individuals with Sjögren’s syndrome. Rheum Dis Clin North Am. 2008;34:1001-1010.
9. Chambers MS, Mellberg JR, Keene HJ, et al. Clinical evaluation of the intraoral fluoride releasing system in radiation-induced xerostomic subjects. Part 2: Phase I study. Oral Oncol. 2006; 42:946-953.
10. Saporito RA, Boneta AR, Feldman CA, et al. Comparative anticaries efficacy of sodium fluoride and sodium monofluorophosphate dentifrices. A two-year caries clinical trial on children in New Jersey and Puerto Rico. Am J Dent. 2000;13:221-226.
11. Wynn RL, Meiller TF, Crossley HL. Drug Information Handbook for Dentistry. 7th ed. Hudson, Ohio: Lexi-Comp; 2001:1247-1248.
12. Daniels TE. Evaluation, differential diagnosis, and treatment of xerostomia. J Rheumatol Suppl. 2000;61:6-10.
13. Baysan A, Lynch E, Ellwood R, Davies R, Petrsson L, Borsboom P. Reversal of primary root caries using dentifrices containing 5,000 and 1,100 ppm fluoride. Caries Res. 2001;35:41-46.
14. Nordström A, Birkhed D. Fluoride retention in proximal plaque and saliva using two NaF dentifrices containing 5,000 and 1,450ppm F with and without water rinsing. Caries Res. 2009;43:64-69.
15. Joyston-Bechal S, Hayes K, Davenport ES, Hardie JM. Caries incidence, mutans streptococci and lactobacilli in irradiated patients during a 12-month preventive program using chlor – hexidine and fluoride. Caries Res. 1992;26: 384- 390.
16. Ship JA, Pillemer SR, Baum BJ. Xerostomia and the geriatric patient. J Am Geriatr Soc. 2002;50:535-543.
17. Gorsky M, Epstein JB, Parry J, Epstein MS, Le ND, Silverman S Jr. The efficacy of pilocarpine and bethanechol upon saliva production in cancer patients with hyposalivation following radiation therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;97:190-195.
18. Frydrych AM, Davies GR, Slack-Smith LM, Heywood J. An investigation into the use of pilocarpine as a sialagogue in patients with radiation induced xerostomia. Aust Dent J. 2002;47:249-253.
19. Braga MA, Tarzia O, Bergamaschi CC, Santos FA, Andrade ED, Groppo FC. Comparison of the effects of pilocarpine and cevimeline on salivary flow. Int J Dent Hyg. 2009;7:126-130.
20. Balasubramaniam R, Alawi F, DeRossi S. Superficial mucoceles in chronic graft-versus-host disease: a case report and review of the literature. Gen Dent. 2009;57:82-88.
21. Hawthorne M, Sullivan K. Pilocarpine for radiation-induced xerostomia in head and neck cancer. Int J Palliat Nurs. 2000;6:228-232.
22. Kao HJ, Lin HR, Lo YL, Yu SP. Characterization of pilocarpine-loaded chitosan/Carbopol nano – particles. J Pharm Pharmacol. 2006;58:179-186.
23. Epstein JB, Decoteau WE, Wilkinson A. Effect of Sialor in treatment of xerostomia in Sjogren’s syndrome. Oral Surg Oral Med Oral Pathol. 1983;56:495-499.
24. Epstein JB, Schubert MM. Synergistic effect of sialagogues in management of xerostomia after radiation therapy. Oral Surg Oral Med Oral Pathol. 1987;64:179-182.
25. Cummins MJ, Papas A, Kammer GM, Fox PC. Treatment of primary Sjogren’s syndrome with low-dose human interferon alfa administered by the oromucosal route: combined phase III results. Arthritis Rheum. 2003;49:585-593.
26. Khurshudian AV. A pilot study to test the efficacy of oral administration of interferonalpha lozenges to patients with Sjogren’s syndrome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;95:38-44.
27. Scully C. Drug effects on salivary glands: dry mouth. Oral Dis. 2003;9:165-176.
28. Dawes C. How much saliva is enough for avoidance of xerostomia? Caries Res. 2004; 38: 236-240.
29. Tschoppe P, Wolgin M, Pischon N, Kielbassa AM. Etiologic factors of hyposalivation and consequences for oral health. Quintessence Int. 2010;41:321-333.
30. Rhodus NL, Bereuter J. Clinical evaluation of a commercially available oral moisturizer in relieving signs and symptoms of xerostomia in postirradiation head and neck cancer patients and patients with Sjögren’s syndrome. J Otolaryngol. 2000;29:28-34.
31. O’Sullivan EM, Higginson IJ. Clinical effectiveness and safety of acupuncture in the treatment of irradiation-induced xerostomia in patients with head and neck cancer: a syste – matic review. Acupunct Med. 2010;28:191-199.
32. Braga FP, Sugaya NN, Hirota SK, Weinfeld I, Magalhães MH, Migliari DA. The effect of acupuncture on salivary flow rates in patients with radiation-induced xerostomia. Minerva Stomatol. 2008;57:343-348.
33. Belch JJ, Hill A. Evening primrose oil and borage oil in rheumatologic conditions. Am J Clin Nutr. 2000;7:352S-356S.
34. Turner M, Jahangiri L, Ship JA. Hyposalivation, xerostomia and the complete denture: a systematic review. J Am Dent Assoc. 2008;139: 146-150.

From Dimensions of Dental Hygiene. January 2011; 9(1): 50, 52-53.